CUSTOMER APPLICATION FORM
Alcon Laboratories, Inc.
6201 South Freeway - WX-21
Fort Worth, Texas 76134 USA
Attention: Data Management
Phone: 1-800-862-5266 Ext. 31587
Fax: 1-800-757-4954 E-Mail: customer.profile@alcon.com
BILLING INFORMATION - SELECT ONE:
❏ Direct Billing
❏ Buying Group - PRE-APPROVAL REQUIRED/CONTACT BUYING GROUP (For Contact Lenses Only)
Buying Group Name: Member #: SHIP TO ADDRESS
BILL TO ADDRESS
ACCOUNT NAME:
ACCOUNT NAME:
ATTN:
DATE STARTED:
ADDRESS:
ATTN:
CITY:
ADDRESS:
STATE:*ZIP:
CITY:
COUNTY:
STATE:ZIP:
CONTACT NAME/TITLE:
COUNTY:
PHONE: (
FAX: (
)
EXT.
CONTACT NAME/TITLE:
)
PHONE: (
)
EMAIL ADDRESS:
FAX: (
)
POST MARKETING ACTION COORDINATOR, NAME/PHONE:
BUSINESS WEBSITE:
EMAIL ADDRESS:
*Vermont Compliant
ACCOUNTS PAYABLE CONTACT/PHONE:
LICENSING INFORMATION
NAME OF LICENSED PRESCRIBER:
PHYSICIAN STATE LICENSE #: (COPY OF LICENSE MUST BE ATTACHED)
SPECIALTY (ie. ophthalmology, optometry, etc.):
IF AN OPHTHALMOLOGIST PLEASE INDICATE ONE OF THE FOLLOWING SUBSPECIALTIES:
❏ RETINA SPECIALIST ❏ REFRACTIVE ONLY SPECIALIST ❏ OTHER:
DEA #:
DEA EXPIRATION DATE:
GLN # (GLOBAL LOCATION NUMBER) if applicable
HIN # (HEALTH INDUSTRY NUMBER) if applicable
LICENSE PERMIT #:EXPIRATION DATE:
(legally authorizing the receipt of prescription drugs/devices) i.e. State Board of Pharmacy, etc.
© 2013 Novartis
5/13
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ORDERING INFORMATION
WHAT ALCON PRODUCTS ARE YOU INTERESTED IN PURCHASING? ❏ OVER-THE-COUNTER PRODUCTS (I.E. OPTI-FREE®, SYSTANE®, etc.)
❏ PHARMACEUTICAL PRODUCTS ❏ SURGICAL PRODUCTS ❏ CONTACT LENSES ❏ OTHER
ARE YOU INTERESTED IN ORDERING CONTACT LENSES AND/OR CONTACT LENS CARE VIA MYALCON.COM?
❏ NO ❏ YES IF YES, WHO:
ARE YOU CURRENTLY WORKING WITH AN ALCON CONTACT?
HAVE YOU EVER HAD AN ACCOUNT WITH ALCON?
❏ NO ❏ YES
❏ NO ❏ YES IF YES, WHEN?:
NAME:ACCOUNT NUMBER:
TYPE OF BUSINESS (CLASS CODE): ❏ HOSPITAL ❏ DR.’S OFFICE ❏ RETAILER ❏ SURGICENTER ❏ WHOLESALER
❏ OPTICIAN ❏ OPHTHALMOLOGIST ❏ DISTRIBUTOR ❏ DISTRIBUTOR ❏ OTHER (PLEASE SPECIFY):
DO YOU ACCEPT BACKORDERS?
❏ NO ❏ YES
DO YOU HAVE PRODUCT DATING MINIMUM REQUIREMENTS?
❏ NO ❏ YES IF YES, SELECT: ❏ 9 months ❏ 12 months (WFS, WVX, RPC)
❏ NO ❏ YES
DO YOU ALLOW PRODUCT SUBSTITUTIONS? ❏ NO ❏ YES
DO YOU WANT TO TRANSMIT ORDERS VIA EDI?
IF PRODUCT SUBSTITUTIONS ALLOWED, PLEASE INDICATE:
DIMENSION CHANGE
UPC CHANGE ❏ NO ❏ YES
❏ NO ❏ YES REBATE IN/ON PACK ❏ NO ❏ YES
DELIVERY INFORMATION
DO YOU REQUIRE PRESCHEDULED DELIVERY APPOINTMENTS?
❏ NO ❏ YES
ADVANCED NOTICE REQUIREMENT:PHONE #:
FINANCIAL INFORMATION
FULL LEGAL NAME OF BUSINESS:
FORM OF BUSINESS (CORPORATION, PARTNERSHIP, SOLE PROPRIETOR, ETC.)
NUMBER OF YEARS IN BUSINESS:
STATE OF INCORPORATION OR REGISTRATION:
PRINCIPALS OR OFFICERS (list below):
NAME:TITLE:
NAME:TITLE:
NAME:TITLE:
PARENT COMPANY NAME (i.e. HEALTHSOUTH, TENET, ETC.):
YOUR BUSINESS ESTIMATED MONTHLY SALES VOLUME: $
ESTIMATED MONTHLY PURCHASES FROM ALCON: $
DO YOU HAVE A STATE TAX EXEMPT CERTIFICATE?
❏ NO ❏ YES IF YES, PLEASE ATTACH A COPY
HAS THE BUSINESS OR ANY OFFICERS FILED A PREVIOUS BANKRUPTCY?
❏ NO ❏ YES
IF YES, PROVIDE THE COMPANY NAME AND DATE FILED:
BANK REFERENCES
BANK NAME:
CONTACT:ADDRESS:
CITY:STATE:ZIP:PHONE:
© 2013 Novartis
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TRADE (VENDOR) REFERENCES
COMPANYCONTACT PERSONPHONE #
1.
2.
3.
Alcon requires that this information be provided for account consideration. Completion of this form, however, does not indicate that a request will be granted.
Customer acknowledges and agrees that the signing of this Customer Application Form shall constitute authorization under the Fair Credit & Reporting Act to
Alcon and its Agents to utilize outside credit reporting agencies to provide reports on Customer in order to permit Alcon to appropriately evaluate the extension
of any business credit. Alcon may also confirm trade and bank references. Customer agrees to release of information to other creditors and reporting agencies
regarding Alcon’s credit experience with them. This authorization will remain valid and enforceable until Customer expressly revokes said authorization in writing
to Alcon.
Customer agrees to pay all charges according to the payment terms as designated on Alcon’s invoices.
Terms and Conditions Agreement
Applicant agrees to pay according to terms and conditions stated herein. Creditor reserves the right to assess a monthly service charge on account paid outside
of credit terms to the maximum amount permitted per jurisdiction. Creditor reserves the right to cease extension of credit without notice or to change terms of
payment pursuant to any disclosure by customer according to section 409 of the Sarbanes Oxley Act. Applicant expressly agrees that it shall be liable and pay
all attorneys’ fees, collection costs and court fees, and any other expenses, whether or not incurred in connection with litigation, including but not limited to
attorneys’ fees and costs associated with the enforcement of any of the terms of this Application and attorneys’ fees and costs resulting from a default under this
Application.
The above information is being provided in conjunction with a request of open credit terms from Creditor and its subsidiaries, divisions and affiliates (collectively
“Creditor”). I hereby certify under penalty of perjury that the information provided is true to the best of my knowledge. The undersigned further understands
that the Guaranty accompanying this Application is necessary to induce Creditor to extend credit to Applicant. If this Application is accepted by Creditor, the
undersigned agrees to the terms and conditions attached to the Application and changed from time to time. The undersigned further agrees that all issues and
disputes relating to any credit arrangement extended hereunder shall be governed in accordance with a competent jurisdiction chosen at the discretion of
Creditor, without reference to conflicts of laws principles.
PRINT AND SIGN NAME (required for processing)
PRINT:
SIGN:
TITLEDATE
FOR INTERNAL USE ONLY:
CLASS OF TRADE:VERIFIED BY:DATE:
© 2013 Novartis
5/13